Chronic Care Management; Getting Paid for Care Coordination

Effective January 1, 2015 there is good news for primary care physicians and other specialists managing patients with chronic illnesses. As outlined in the 2015 PFS Final Rule, Medicare will now pay for Chronic Care Management ("CCM") services representing previously unreimbursed non-face-to-face case management activities that occurred beyond what was included into the face to face payment for Evaluation and Management ("E&M") services.[1]

CMS adopted CCM (CPT code 99490) at the MPFS national payment of $42.91, per 30 day period, defined in the CPT Professional Codebook as follows:

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised or monitored.[2]

CMS complements the CPT definition by articulating the following activities as counting toward the 20-minute requirement:

Systematic assessment of the beneficiary's medical, functional and psychosocial needs;

Provision or oversight of all recommended preventive services;

Medication reconciliation with related oversight of beneficiary's adherence to and compliance with prescribed medication(s);

Non face-to face services such as disease management/educations; addressing questions from family members/caregiver; identification of and referral to community resources and communication with home health agencies and other community service providers.

The three overarching requirements for the provision and billing of CCM services include the following:

1. Beneficiary's Written Consent: Prior to billing CCM, a provider must inform an eligible beneficiary about the availability of the CCM services and obtain their written consent to receive the services. The consent is to include the following elements:

Description of the CCM and how to access to CCM;

Acknowledgement that only one practitioner at a time can furnish and be paid for CCM;

Beneficiary's authorization for the electronic communication of their medical information with other providers as part of care coordination;

Beneficiary's right to revoke the CCM services at any point, (effective at the end of a calendar month) and the effect of the revocation.

2. Capability to Use "CCM certified technology": In order to report and be paid for CCM services, CMS requires that providers use Electronic Health Record (EHR) technology that has been certified under the ONC Health IT Certification Program. The CCM service must be furnished "using, at a minimum, the edition(s) of certification criteria that is acceptable for purposes of the EHR Incentive programs as of December 31st of the calendar year proceeding each PFS payment year." For 2015, CMS is allowing an EHR that that satisfies meaningful use criteria for 2011 or 2014. The certified EHR enables providers to meet the following electronic technology requirements in the provision of CCM:

Creation of a clinical summary record that can be transmitted electronically (other than by fax);

Creation of the required care plan that will be available on a 24/7 basis to all practitioners within the practice whose time counts toward the time requirement to bill the CCM code;

Sharing of the care plan electronically (other than by fax) with other practitioners and providers;

Communication regarding care coordination to and from home and community based providers regarding the patient's psychosocial needs and functional deficits;

Documentation of the beneficiary's written consent.

3. Access to Care: A provider offering CCM services must ensure the following practice capabilities for eligible beneficiaries:

Access to care management services 24/7; defined by providing the beneficiary with a means to make timely contact with health care providers in the practice to address his/her urgent needs;

Maintaining the continuity of care through successive appointments with a designated provider or member of the care team;

Enhanced opportunities for the beneficiary and any caregiver to communicate with the practitioner by telephone, secure messaging, internet or other asynchronous consultation methods;

Management of care transitions between and among health care providers and settings.

With the roll-out of the reimbursement for this service, there are questions/issues raised that require further clarification by CMS as follows:

CMS does not currently endorse a specific list of chronic conditions for providers. For initial guidance, providers can refer to the CMS Chronic Conditions Warehouse that currently identifies 27 chronic conditions. https://www.ccwdata.org/

With regard to eligible practitioners, CMS has identified physicians (of any specialty), advanced practice registered nurses, physician assistants, clinical nurse specialists and certified nurse midwives as those who can furnish the full range of CCM services under the benefit, and only to the extent permitted by applicable limits on their state scope of practice.

What has engendered some confusion is CMS's use of the term "clinical staff" when discussing who can provide, versus bill, these services. CMS states that clinical staff must meet the requirements for auxiliary personnel under "incident to" services. CMS made an exception for CCM services requiring general versus direct supervision when services are rendered "incident to." This is in acknowledgement that CCM services are intrinsically non-face to face.

Making it Work

Making a CCM program operational may not be easy, unless your EHR has a CCM module available. While some of the CCM requirements might already be part of your work flow processes; i.e. your practice is certified as a Patient Centered Medical Home, for documentation and billing, your EHR will need to do the following:

Fulfill the aforementioned electronic documentation requirements;

List all patients eligible for the CCM service;

Determine which patients have signed the CCM consent agreement;

Remove any patients that had CCM services billed in the current 30 day period;

Track minutes of CCM rendered in a calendar month;

Create a bill each 30 day period with the CCM code, ensuring the patient has not received one or more of the following services in the same calendar month; transitional care management, home healthcare supervision, hospice care supervision, ESRD services (CPT 90951-90970).

Providers will need to weigh the costs of implementation with the potential in increased revenue. In addition to increased revenue, processes put in place to bill CCM services will enable the provider to obtain valuable experience when transitioning from a fee-for-service to a value based reimbursement model.